Managed Long-Term Care Quality Workgroup July 22, 2014

Workgroup Charge The charge of MLTC Quality Incentive Workgroup is to advise the Department of Health on using measures of quality, satisfaction, compliance and efficiency to create a total quality score. The total quality score will be the basis for payment distribution for the MLTC Quality Incentive.

Structure Structure will be similar to other Quality Incentives evaluated by the DOH, actual measures are still being considered and discussed. Quality Measures Utilizing UAS-NY data Satisfaction Measures Biennial survey of members Compliance Measures Timely submissions of required reports or assessment information Efficiency Measure Potential Avoidable Hospitalizations

Recently emailed materials We provided UAS questions that feed numerator and denominator of the proposed Quality Measures We used Oct-Dec 2013 UAS data and provided crude rates/ranges for the proposed QI Quality Measures

Summary of Issues Raised at May 19, 2014 Meeting Category Issue Decision Quality Falls with medical intervention. This measure is intended to capture severe falls. Including all members in the denominator will change the measure magnitude and get past potential issues with underreporting falls that do not need medical intervention. This is consistent with the NQF endorsed measure in “Long-stay nursing home care: percent of residents experiencing one or more falls with major injury”. The previous approach used a denominator more consistent with the HEDIS measure. Include all members in the denominator, not just members who fell. Medication administration. This measure is intended to capture independence and is consistent with national measures. Set up is not independence. Set up will not be considered independent. Efficiency PAH: primary vs. admitting diagnosis. Group wants to use the primary diagnosis to represent why the member sought care. In CMS demo project primary diagnosis was used, however, admitting diagnosis was used for PAH measure in nursing home quality initiative. Use primary diagnosis consistent with CMS. Satisfaction Satisfaction survey questions. Include questions about Consumer Directed Personal Assistance and about consistency of HHAs. New questions will be added to the next satisfaction survey, if possible. Rating of plan. Keep this measure. Retain rating of plan in the quality incentive. Evaluate timeliness measures by region. No analysis of timeliness by region. Consumer Satisfaction rating of care manager and HHA. Add rating of care manager and rating of HHA.

Summary of Issues Raised at May 19, 2014 Meeting - continued Category Issue Decision Methodology Number of measures (quality, satisfaction, PAH) to be included in the quality incentive. Reweighting of plans with missing measures will not shift the benchmark (statewide average). Six plans have SS PAH values. Seventeen plans have 7/7 NS or SS for satisfaction measures. Two plans have 3/7 or 4/7 NS or SS for satisfaction measures. Include five quality measures, seven satisfaction measures, one PHA measure in the quality incentive. Plans with some NS/SS satisfaction measures will have the denominator adjusted using the same method as for those plans that had no satisfaction measures at all. Risk-adjustment by MAP/PACE/partial. No quality measure risk-adjustment by plan type. Medicaid rates are not adjusted by plan type. Risk-adjustment in general. Risk-adjustment has historically been based on responses from the preceding assessment. A previous UAS assessment is not yet available. Therefore, only factors from the current assessment that can be assumed to precede the quality indicator outcome will be used. These results may not be comparable to subsequent results which will use the historical risk- adjustment approach. Evaluate sex and age as risk adjustors for risk-adjusted measures. Will use prior UAS-NY assessment for risk adjustors in the future. Miscellaneous Remove NH residents from the denominators of quality measures. Exclude NH members in NH at time of assessment this year and revisit this exclusion for subsequent years. Hospice. Consider removing hospice members from all measures. End stage disease is on the functional supplement. 97% of MLTC members have a functional supplement. Include members with end stage disease in denominators. End stage disease will be evaluated as a risk adjustor for weight loss and other measures. Number of measures: Original satisfaction measures: rating of health plan involved in decisions advanced directives timeliness of HHA help manage illness Additional satisfaction measures: Rating of care manager Rating of HHA Risk-adjusted quality and satisfaction measures no falls requiring medical intervention no ER visit no severe or more intense daily pain not lonely and distressed independent medication management rating of care manager rating of HHA  

Small Sample Size Quality/Satisfaction Measures PAH Measure Will not reweight for Small Sample Size or Not Surveyed Will reduce Quality points and Satisfaction points total Example If satisfaction points are worth 40 out of 100 possible points, total score for plans with no reported satisfaction results would be 60 not 100. If plan has SS for one measure, base will be reduced Based on the 2013 Managed Long-Term Care Annual Report 9 plans not surveyed 7 plans consistently small sample sizes PAH Measure Total Quality Score will be reduced for Plans with sample size too small to report on the PAH measure. Base will be 90 points instead of 100

Proposed Quality Measures Percentage of members who received an influenza vaccination in the last year Risk-adjusted percentage of members who did not have falls resulting in medical intervention in the last 90 days Risk-adjusted percentage of members who did not have an emergency room visit in the last 90 days Risk-adjusted percentage of members who did not have severe or more intense daily pain Risk-adjusted percentage of members who were not lonely and distressed

Proposed Satisfaction Measures Risk-adjusted percentage of members who rated their managed long-term care plan as good or excellent Risk-adjusted percentage of members who responded that they were usually or always involved in making decisions about their plan of care Percentage of members who responded that a health plan representative talked to them about appointing someone to make decisions about their health if they are unable to do so Risk-adjusted percentage of member who reported that within the last 6 months the home health aide/personal care aide services were always or usually on time Risk-adjusted percentage of members who rated the helpfulness of the plan in assisting them and their family to manage their illnesses as good or excellent Risk-adjusted percentage of members who rated the quality of care manager/case manager services or supplies within the last 6 months as good or excellent Risk-adjusted percentage of member who rated the quality of home health aide/personal care aide services or supplies within the last 6 months as good or excellent

Proposed Compliance Measures MEDS – No statement of deficiency for timeliness or completeness of MEDS III submission for measurement year 2013 MMCOR - No statement of deficiency for timeliness or completeness of Medicaid Managed Care Operating Reports submission for measurement year 2013 Ratio - Meds vs. MMCOR ratios of at least 75% - encounter data gross dollars must represent at least 75% of MMCOR reported medical expense for measurement year 2013 Provider Network - No statement of deficiency for incomplete or inaccurate provider listings and/or failure to maintain at least 75% provider participation rate for measurement year 2013

Efficiency Measure - Potentially Avoidable Hospitalization (PAH) Measure Using the same methodology as the 2013 MLTC Report, except we will use primary diagnosis instead of admitting diagnosis to identify PAH Using SAAM 2013 data (only January to June data due to the switch to UAS-NY), each enrollees information is matched to the SPARCS 2013 inpatient dataset A series of identifying data on the SAAM dataset will be used to identify enrollee’s hospitalizations Enrollees without a hospitalization are dropped from PAH analysis Members who are enrolled in a plan less than 3 months prior to the hospitalization are dropped from PAH analysis A hospitalization is considered potentially avoidable if any one of the following conditions is the primary diagnosis heart failure, respiratory infection, electrolyte imbalance, sepsis, anemia, or urinary tract infection The PAH measure is calculated by dividing the total number of avoidable hospitalizations (numerator) by the number of plan days (denominator), multiplied by 10,000

Scoring Quality Measures – 40 points Satisfaction – 40 points Points awarded based on the statewide range of scores < 50th percentile receive no points >=50th to <75th percentile – receive 50 percent of possible points for a measure >=75th to <90th percentile – receive 75 percent of possible points for a measure >=90th percentile – receive 100 percent of possible points for a measure Satisfaction – 40 points Points awarded based on plan performance to the statewide average Full points will be received for results significantly better than the statewide average Half points will be received for measures with results not significantly different from the statewide average And no points for measures with results significantly lower than the statewide average Compliance – 10 points Each measures is 2.5 points Efficiency – 10 points

Proposed Timeline Timeline |---------------------------------------------------------------------------------------------------|-------------------------------|----------------------|-------------------| Jan. 2014 June 2014 Mid July 2014 Sept 2014 Oct 2014 Nov 2014 Data closes Finalized DataMart refresh Calc. QM/QI Report/Guides for attribution Proposed retro-rate adjustment for period 4/1/14-3/31/15 process on or before 1/1/2015

Attribution of UAS-NY Assessments Issue Unit of analysis is person-plan Current UAS-NY assessments are not stamped with plan id UAS-NY organization id fields may contain plan id organization id subcontractor id—may be another plan Resolution Claims data Medicaid number, plan id, capitation payment dates UAS-NY data Medicaid number, organization id, assessment date Attribute assessment to plan if Medicaid numbers are the same Assessment date is in a month capitation payment was received Initial assessment date is up to 42 days before first capitation payment UAS-NY org. field is a plan id, org. id, or subcontractor id used by the plan id on the claim

Questions? $65, million yr 1. FIDA will have separate pool. Stability of measures year to year.